MEDICARE: DR. TYLER JUSTIN BOWEN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	37376	TX

General Provider Information

NPI Number	:	1477123883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TYLER JUSTIN BOWEN DDS

Provider Business Mailing Address
First Line	:	3511 LAKE LUGANO CIR
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77493-4067
Country	:	US
Telephone Number	:	210-535-7360
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 W MONTGOMERY ST STE B
Second Line	:
City	:	WILLIS
State	:	TX
Zip	:	77378-8827
Country	:	US
Telephone Number	:	936-701-5010
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2021
Last Update Date	:	06/28/2021

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